House Republicans Tout State-Level Programs on Overdose Prevention

— But Democrats argue that Medicaid cuts will overwhelm such efforts

WASHINGTON -- A House hearing that was supposed to focus on states' efforts to curb the opioid crisis quickly split into two different narratives, with Republicans trying to stick to that agenda while Democrats focused on possible effects of huge cuts to the Medicaid program.

The opioid epidemic has made headlines far too often, and hardly a day passes without a news article of another child finding a parent whose overdosed, said Rep. Diane DeGette (D-Colo.) during the House Energy and Commerce subcommittee on Oversight and Investigations hearing.

Subcommittee Chairman Tim Murphy (R-Pa.) called it "one of the worst medical tragedies of our times."

Several members cited a New York Times analysis that has reported that more than 59,000 people died from drug overdoses in 2016 -- up from about 52,000 in 2015 -- making such overdoses the number one cause of death for Americans under 50.

Murphy highlighted the programs developed in state governments such as Kentucky's All-Schedule Prescription Electronic Reporting System (KASPER) and Rhode Island's AnchorED which pairs overdose survivors with peer recovery coaches. Virginia also has a standing order that allows pharmacies to dispense naloxone without a prescription.

During the hearing Murphy focused on the challenge of screening for mood disorders -- since more than half of the people who are addicted to opioids also have depression or anxiety -- the need to increase the number of psychiatrists and certified drug counselors in rural areas, and promoting the use of licensed treatment providers in emergency rooms.

"Coverage without access and access without coverage are both problems," he said, emphasizing the need for better data to know which strategies are effective.

Republicans focused on many of these issues of research and doctor shortages, whereas DeGette wanted witnesses to address what she called "the fly in the ointment": Medicaid cuts.

The Senate's Better Care Reconciliation Act would reduce the Medicaid budget by roughly $770 billion over 1o years, according to estimates from the Congressional Budget Office. Of the 22 million anticipated to become uninsured through that bill, 15 million would otherwise be covered by Medicaid, the CBO said. Cuts of a similar magnitude are also part of the House-passed American Health Care Act.

DeGette stressed that she was pleased by the impact the 21st Century Cures Act has had on the epidemic -- the bill provides $1 billion in state grants -- and by the many new programs that have developed as a result.

However, even the proposed addition of $45 billion to the BCRA would not make up for the millions of patients who would lose Medicaid coverage under the new bill.

She proceeded to ask witnesses directly whether Medicaid cuts in the Senate bill would hurt their states.

Rebecca Boss, director of the Rhode Island Department of Behavioral Healthcare for the Developmental Disabilities and Hospitals, answered that the bill would indeed have a damaging effect.

Rhode Island's work to reverse the opioid crisis was touted several times during the hearing as a model for the country.

At least three of the four strategies used in Rhode Island are funded by Medicaid, Boss told MedPage Today: prevention, naloxone reversal, and treatment (e.g., buprenorphine and naltrexone).

"Recovery efforts are not necessarily supported by Medicaid but because we're able to use funding though insurance to support the treatment, we're not required to use our Substance Abuse Prevention and Treatment block grant to fund that treatment for the uninsured. So, we're able to use that money to support the recovery efforts such as the AnchorED, (peer recovery program) ... to try to engage individuals in treatment."

Rhode Island also has Medicaid-funded health homes which provide care coordination and case management for people to receive care in opioid treatment homes and have both improved outcomes and reduced costs, she said.

When Brian Moran, Virginia's Secretary of Public Safety and Homeland Security, was asked whether Virginia would have been helped by Medicaid expansion, he agreed that it would. The state has not accepted the expansion despite efforts by its Democratic governor.

"More people would have access to treatment," Moran testified.

However, other state officials were less certain of Medicaid's importance for overdose prevention. Kentucky's John Tilley tried to say so but DeGette immediately started questioning another witness.

Tilley told MedPage Today after the hearing, "I think there's more than one way to skin a cat ... During the period of Medicaid expansion we've seen our overdose death rates go up substantially. We've seen some prescribing behavior go down, but overall the problem has simply worsened with regard to heroin and fentanyl now."

He noted that in Kentucky the corrections system has made an impact on the opioid crisis using state tax dollars and through creative use of funding from the 21st Century Cures Act.

"I think the discussion does need to continue about the most effective way to fund treatment ... I do agree that we need treatment that follows the individual well outside that crisis stabilization phase into long term recovery, but I think that there are many ways to approach that," adding that Medicaid is simply one of many options.

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